Conventional Topical Treatments for Alopecia Areata

Most of the prescription topical treatments for alopecia areata are steroidal.

Many cases of mild to moderately severe alopecia areata resolve without treatment. In fact, some studies have shown little benefit from any treatments for patients with 40% or less scalp involvement.(121418)

That said, a number of different treatment options are available for alopecia areata in both the beard and scalp. These include both topical and systemic drugs. Research also suggests combining some of topical treatment therapies (such as latanoprost or garlic gel and betamethasone valerate) may improve outcomes.(139425)

In more severe cases, first-line treatment options to consider include topical or non-systemic treatments involving ointments, gels, and skin injections at the site of hair loss. Drugs used either suppress or stimulate the immune system response.(121)

CONVENTIONAL TOPICAL MEDICAL TREATMENT OPTIONS FOR
ALOPECIA AREATA, ALOPECIA TOTALIS, AND ALOPECIA UNIVERSALIS
AGENT HOW IT WORKS
EVIDENCE OF BENEFIT
SIDE EFFECTS
RECOMMENDED
DOSAGE OR USE
Anthralin

Question: How does anthralin work to treat alopecia areata?

Answer: Anthralin stimulates free radicals and causes an inflammatory response that suppresses the overactive immune system.(121)

Question: Can anthralin regrow hair?

Answer: Anthralin induces acceptable regrowth in most patients with patchy alopecia areata and about 25% in those with alopecia totalis.(121)

Question: What are the potential side effects of anthralin?

Answer: Common/reported adverse side effects for anthralin include:(121)

  • Contact dermatitis
  • Itchiness
  • Superficial skin infection
  • Swollen regional lymph nodes
Topical immunotherapy cream in concentrations ranging from 0.2-1%.(121)
Bexarotene

Question: What is bexarotene? How does bexarotene help treat alopecia areata?

Answer: Bexarotene is a synthetic retinoid that has regulating effects on the immune system.(129)

Question: Can bexarotene regrow hair?

Answer: In a 6-month clinical trial involving 42 adult patients with alopecia areata ranging from patchy to full loss of hair, topical bexarotene 1% gel was tested on half of each patient's scalp. Eleven of the patients experienced 50% or more regrowth of hair—including 6 patients who regrew hair on both sides of the scalp. One patient who was nonresponsive during the trial period showed significantly more growth on the treated side when later administered oral prednisone.(129)

Question: What are the potential side effects of bexarotene?

Answer: Common/reported adverse side effects for bexarotene include:(121129)

  • Mild skin irritation (74% of patients)
  • Severe skin irritation (12% of patients)
Gel, 1%; applied twice a day.(129)

Betamethasone Dipropionate

(Diprosone®)

Question: What is Diprosone®? How does Diprosone® help treat alopecia areata?

Answer: Diprosone® is an anti-inflammatory steroid that helps suppress the immune system response in hair follicles.(121)

Question: Can Diprosone® regrow hair?

Answer: On average, about 60% of patients have a good to excellent response in with Diprosone® that is maintained in about 70% of patients. Regrowth starts within 3 months.(121)

Question: What are the potential side effects of Diprosone®?

Answer: Common/reported adverse side effects of Diprosone® include:(121)

Topical steroid cream; 0.05% concentration twice a day.(121)

Betamethasone Valerate

Question: What is betamethasone valerate?

Answer: Betamethasone valerate is a topical steroid foam.(426427)

Question: Can betamethasone valerate regrow hair?

Answer: Topical steroid foam can be an effective, safe treatment for AA. One study involving patients with mild-to-moderate AA suggests betamethasone valerate foam works significantly better than betamethasone dipropionate lotion. Another study showed the foam worked better than tacrolimus, but not as well as triamcinolone acetonide injections.(426427)

Question: What are the potential side effects of betamethasone valerate?

Answer: Reported side effects are mild and include itchiness, skin pigment changes, and local inflammation of hair follicles. However, potent topical corticosteroids can cause damage to facial skin and facial treatment should be limited to less than 2 weeks.(426427)

Topical betamethasone valerate foam (0.1%) twice daily for 3-12 weeks (per clinical studies).(426)
Clobetasol Propionate

Question: What is clobetasol propionate? How does clobetasol help treat alopecia areata?

Answer: Clobetasol is an anti-inflammatory steroid.(121)

Question: Can clobetasol regrow hair?

Answer: Clobetasol stimulated hair regrowth in 28.5% of patients with hard-to-treat alopecia totalis and alopecia universalis. Hair regrowth was seen within 8-14 weeks of the 6-month study.(121)

Question: What are the potential side effects of clobetasol?

Answer: Common/reported adverse side effects of clobetasol include:(121)

2.5-g of this steroid cream 6 days a week with a tight plastic film wrapped over the treated area.(121)

Fluocinolone Acetonide

(Synalar-HP)

Question: What is Synalar?

Answer: Synalar is an anti-inflammatory steroid.(121)

Question: Can Synalar regrow hair?

Answer: In clinical studies, Synalar prompted good to excellent regrowth in 61% of patients. Regrowth was maintained in 71% of patients and began within 3 months.(121)

Question: What are the potential side effects of Synalar?

Answer: Common/reported adverse side effects of Synalar include:(121)

Topical steroid cream; 0.2% concentration twice a day.(121)
Prostaglandin Analogs

Question: What are prostaglandin analogs? What is latanoprost? What is bimatoprost?

Answer: Prostaglandins are steroid analogs initially used to treat glaucoma when it was noticed that a side effect was eyelash growth.(130)

Question: Can latanoprost regrow hair? Can bimatoprost regrow hair?

Answer: Study results are mixed but suggest that these prostaglandin analogs may work better in patients with less severe alopecia areata of the eyelashes.(130)

Question: What are the potential side effects of latanoprost? What are the potential side effects of bimatoprost?

Answer: Common/reported adverse side effects of latanoprost or bimatoprost include:(5121)

  • Hair darkening
  • Mild eye irritation
Latanoprost or bimatoprost; both are topically applied to eyelash area.(130)

Minoxidil

Question: What is minoxidil? How does minoxidil work?

Answer: Minoxidil is a follicle cell growth stimulator. Lab studies suggest minoxidil may help regulate immune system response as well.(121131)

Question: Can minoxidil regrow hair?

Answer: Minoxidil produces regrowth in up to 45% of patients with 50-99% hair loss when used in the 5% concentration, but appears to be ineffective for alopecia totalis or universalis.(121)

Effectiveness in alopecia areata is dose dependent; the response rate using 5% minoxidil was 81% compared to only 38% using 1% topical minoxidil.(130)

Regrowth is typically seen by 12 weeks of treatment with minoxidil. As with other forms of alopecia, minoxidil must continue to be used in order to sustain the hair regrowth.(121)

Question: What are the potential side effects of minoxidil?

Answer: Common/reported adverse side effects of minoxidil include:(121)

Topical growth stimulator used at 5% concentration for the best effect; 25 drops or less applied twice a day.(121)
Topical immunotherapy Drugs

Question: What is topical immunotherapy? How does topical immunotherapy work?

Answer: Topical immunotherapy involves applying compounds known to cause an allergic response to the skin. In time, this repeated exposure reduces immune system sensitivity and allows hair regrowth.(121)

Question: Can topical immunotherapy regrow hair?

Answer: Clinical studies indicate topical immunotherapy has an average success rate of 30-50% in patients with severe alopecia areata given weekly treatments. While only 17.4% with complete hair loss regrew hair, 100% of those with less than 50% hair loss saw acceptable regrowth, as did the majority of those with 50-99% hair loss.(121)

Overall the response was maintained in 82% of those who continued treatment over a five-year period, whereas only 57% of those who stopped topical immunotherapy. Half of the scalp is treated at a time to judge efficacy. (121)

Hair regrowth begins after an average of 11 weeks of topical immunotherapy. However, maintenance treatments are typically needed.(121)

Question: What are the potential side effects of topical immunotherapy?

Answer: Reported adverse side effects of topical immunotherapy include:(121)

  • Confetti-like speckles of hyper and hypopigmentation (uncommon)
  • Hives
  • Hypopigmentation changes at site of application (6.7-7.5%)
  • Mild skin irritation (most common)
  • Swollen lymph nodes

Squaric acid dibutylester (SADBE) and diphencyprone (DPCP) in concentrations of 0.0001-2% (beginning at 2% for the first weekly application).(121)

Note: safety studies have not been done on these agents and neither is approved by the U.S. Food and Drug Administration. However, DPCP and SADBE have been tested with the Ames assay and there were no indications that either is mutagenic to DNA, and topical immunotherapy drugs have been used for almost 2 decades without reported adverse effects.(121)

Triamcinolone Acetonide

(Kenalog®)

Question: What is Kenalog®?

Answer: Kenalog® is an anti-inflammatory steroid.(121)

Question: Can Kenalog® regrow hair?

Answer: Kenalog® is considered a first-line therapy for alopecia areata. It stimulates hair regrowth in most people with alopecia areata and alopecia totalis, but not with alopecia universalis.(121)

Relapse rates are reportedly between 29% and 72% within 3 months after Kenalog® treatment. Alopecia totalis had the highest rate of relapse.(132)

Question: What are the potential side effects of Kenalog®?

Answer: Reported adverse side effects of Kenalog® include:(121)

  • Skin irritation
  • Unwanted hair growth in distant places (minimal)
Injections every 4-6 weeks; typical concentration is 5 mg/mL divided in multiple shots of less than 0.1 mL/cm over affected scalp area.(121)
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Topical immunotherapy drugs.(121)
Atrophy.
Folliculitis.
Telangiectasias.
Atrophy.
Folliculitis.
Telangiectasias.
Atrophy.
Folliculitis.
Telangiectasias.
Rogaine®
Areas of shrinking, wasting skin.